Update on Office-Based Surgery Proposals

Lisa Percy, J.D., Manager
State Legislative and Regulatory Affairs


Office-Based Surgery
Oregon — Richard R. Johnston, M.D., testified on behalf of the Oregon Society of Anesthesiologists to the Oregon Board of Medical Examiners regarding proposed office-based surgery rules. Written comments also were submitted. The proposal reviewed at the January meeting would require accreditation if the facility provides procedures or surgery using conscious sedation, deep sedation, major conduction block or general anesthesia. Classification of accreditation would vary according to the type of procedure performed, nature of sedation and condition of patient. Class A accreditation would be limited to facilities where tumescent liposuction is performed. Class B would apply to conscious sedation and surgical procedures that pose little risk of complications. Class C would be limited to procedures requiring general anesthesia or major nerve blocks.

With respect to a Class B facility, the physician and health practitioner administering anesthesia (anesthesiologist or nurse anesthetist) would be currently trained in advanced cardiac life support (ACLS); all health practitioners would be encouraged to have training in basic life support (BLS). Sedation would be administered by a qualified practitioner (surgeon, anesthesiologist or nurse anesthetist). With respect to a Class C facility, anesthesia would be administered by an anesthesiologist or nurse anesthetist who is currently ACLS-trained. At least two practitioners currently trained in ACLS or pediatric advanced life support (PALS) would be on the premises at all times. The practitioner administering deep sedation or anesthesia and/or monitoring the patient would not play an integral role in performing the surgical procedure.

The physician performing the surgery or anesthetic procedure would be encouraged to evaluate and document the patient’s condition, risks associated with the treatment plan and be satisfied that the procedure is within the scope of practice of the provider’s and facility’s capabilities. Patients with pre-existing medical problems or other conditions and at undue risk for complications would be encouraged to be referred to an appropriate specialist for preoperative consultation. The rules would encourage a separate anesthetic record.

The rules would address reporting requirements and discharge evaluation and criteria. Adverse incidents in a Class B or C facility that result in death, resuscitation or emergency transfer would be reported to the board within 10 days of the incident. The physician or podiatric physician responsible for the anesthesia or who performed the surgery would report such incidents. The rules would encourage office personnel to be familiar with a documented plan for the transfer of patients to a nearby hospital and would list the required equipment in each facility.

Indiana — As reported in previous articles, the medical board is in the process of implementing S.B. 225, which directs the board to adopt rules that refer to the American Medical Association’s Office-Based Surgery Core Principles. The Indiana Society of Anesthesiologists has worked with the board in drafting the rules.

Wisconsin — S.B. 434 would require the medical board to promulgate rules regarding the administration of anesthesia in an office-based setting. The rules would apply to moderate sedation, deep sedation, regional and general anesthesia. Anesthesia would be administered by a physician who meets training and education standards set by the board or by an individual under the direct supervision of a physician who meets the board’s standards. At least one physician who is trained in advanced resuscitative techniques would be present or immediately available. Appropriate resuscitative equipment would also be present or immediately available until the patient is discharged. Written procedures and policies regarding the administration of anesthesia, pre-anesthesia counseling for each patient, patient monitoring, recovery, record keeping and discharge of each patient would be established in each office. Adverse incidents related to surgery, special procedures or the administration of anesthesia would be reported to the board.

Legislation Introduced to Codify Existing Supervision Requirements
New Jersey — A.B. 4445 would authorize the administration and monitoring of general or regional anesthesia in a hospital or ambulatory surgical center to be performed by an anesthesiologist; a nurse anesthetist who is supervised by an anesthesiologist or a physician who is privileged by a licensed hospital to administer or supervise the administration of anesthesia services. The supervising anesthesiologist or physician would be immediately available during surgery. With respect to conscious sedation, the administration and monitoring of conscious sedation would be performed by an anesthesiologist; a physician who is privileged by a licensed hospital; nurse anesthetist who is supervised by an anesthesiologist or a physician who is privileged by a licensed hospital to administer or supervise the administration of anesthesia services; or a registered professional nurse for the purposes of administering supplemental doses only.

Additionally the legislation would codify provisions found in the office-based surgery regulations. The administration and monitoring of general or regional anesthesia would be performed by an anesthesiologist or a nurse anesthetist under the supervision of an anesthesiologist or a physician who is privileged by a licensed hospital or Board of Medical Examiners (BME) to administer or supervise the administration of anesthesia services. The supervising anesthesiologist or physician would be physically present during the surgery.

The administration and monitoring of conscious sedation would be performed by a physician who is privileged by a licensed hospital or BME to provide conscious sedation; a nurse anesthetist supervised by a physician who meets the privileging requirements described above; or a registered professional nurse or physician assistant who is trained and experienced in the use and monitoring of anesthetic agents at the specific direction of a physician who holds privileges. The supervising physician would be physically present during the surgery.